KEY WORDS: Birth Trauma-Chiropractic-Exercise-Rehabilitation

INTRODUCTION

Birth trauma is a term used to describe a variety of conditions resulting from the malpositioning of the fetus. The events leading to this trauma usually occur after the descent of the infant into the birth canal before delivery, regardless of whether that delivery is vaginal or by caesarean delivery. Malpositions can occur as a result of the infant being in an atypical position for a prolonged period of time. This can also happen with the presentation of multiple births causing fetal malpositioning. Some typical injuries may involve the acromio-calvicular joint, the scapula, the cervical spine, the ilio-femoral joint, and the upper and lower extremities. The acromio-clavicular-humeral joint and the cervical spine usually are the primary sites of these conditions.

CASE REPORT

    An infant was born via caesarean section following the medical induction of labor of a Class C diabetic, multiparous 39-year-old mother at term. This was her tenth pregnancy. She had seven living children. A caesarean section was performed for a mentum posterior brow presentation; this is not compatible with a vaginal birth [1]. William's Obstetrics states that "with a brow presentation, that portion of the fetal head between the orbital ridge and the anterior fontanel presents at the pelvic inlet. The fetal head thus occupies a position midway between full flexion (occiput) and full extension (mentum or face). Except when the fetal head is small or the pelvis is exceptionally large, engagement of the fetal head and subsequent delivery cannot take place as long as the brow presentation persists" [1]. The delivery was uncomplicated. The Apgar score was 8 at 1 min and 9 at 5 min. The Apgar score is a system of scoring the infant's physical condition one minute after birth. The heart rate, respiration, muscle tone, response to stimuli, and color are each rated 0, 1, or 2. The maximum score is 10. Those with low scores require immediate attention if they are to survive. The test may be repeated at 5 or more minutes after birth to judge recovery of infants [2].

    Once home, the parents observed that the infant would often cry out as if in pain when her shoulder was touched or when the newborn's head was flexed. The parents further noted that the infant was often comfortable only when she arched her back and neck and turned her head slightly to the left. The infant exhibited pain by screaming when the left acromioclavicular joint was touched, and audible clicking occurred in the acromio-clavicular joint and scapular region with movement of the left arm. Audible clicking or crepitus may represent synovial villi that have formed "rice" particles that damage the cartilage plates, cause "joint mice" to form and may lead to painful "catches" in the joint which prevent smooth motion. It is important to correct this condition when it first appears. It is also important to consider cervical spine fracture, traumatic subluxation-dislocation, or torticollis when an infant has rigidity of the cervical spine. Radiographic studies, often very difficult to interpret, may not show fracture, dislocation, or callus formation with partial healing [3]. MRI's or Cat Scans may therefore be necessary. In this particular case, the newborn was released for conservative care by a pediatric neurologist after a complete radiographic, neurological, orthopedic, and postural exam in which no medical complicating factors were noted. The medical recommendations were to encourage normal position as much as possible using blanket rolls and head supports. The newborn was then referred to our office by her pediatrician and obstetrician.

    Although the exact causative factor is unknown, structural changes may occur during the birthing process, even with a caesarean section. Here, a Type 2 acromio-clavicular joint injury and an upper cervical subluxation occurred due to the malpositioning of a brow presentation. A Type 2 acromioclavicular dislocation is one in which the acromioclavicular ligaments are disrupted, there is instability of the acromio-clavicular joint, the distal clavicle is rocked inferior (or posterior) and the coracoclavicicular ligaments are partially torn but functionally intact [4]. Radiographs may show a widened joint space.

    At her first visit, the baby was a 62-day-old female infant. She weighed 12.5 pounds and was 21 inches in length. A sensitive area was localized at the acromio-clavicular joint and the superior aspect of the scapula. During the examination the infant would cry out with a high-pitched scream when the acromio-clavicular joint was palpated. Her back would arch and her head would be thrown posterior and lateral. The mother stated that she could not hold her chest to chest. The newborn had to be held with her back toward the mother's chest. Putting the child in any other position caused her to scream. The child would position herself likewise while laying in the crib unsupported. She would not use her left arm. Upon motion palpation, a left laterality of atlas was noted. Antero-posterior and lateral shoulder radiographs showed a normal shoulder with a slightly widened joint space. After a complete chiropractic, orthopedic, and neurologic examination and a review of radiographic studies, a diagnosis of Type 2 acromio-clavicular dislocation and upper cervical subluxation was made.

    The patient was administered a light thumb contact adjustment to correct the left laterality of atlas. Next, the patient was administered specific chiropractic biomechanical adjustments to the acromioclavicular joint. The adjustments were performed in the following manner: the patient was placed seated on the mother's lap with support. The doctor stood on the left side of the patient. The metacarpal phalangeal pad of the right hand was placed on the acromial process and the scapula was stabilized with the right index, middle, and ring fingers. A lowforce, high-velocity thrust was administered superior to inferior and slightly posterior to anterior while rocking the scapula back and down with a hold at the end of the thrust.

    After the adjustment, as the mother continued to hold the baby, passive stretching in the normal range of motion of the shoulder was performed in a gentle, controlled motion. Passive stretching refers to a technique in which the patient does not participate in the movement through the range of movement. The passive stretching technique was chosen because it is most effective when the patient is unable to help, when attempts to relax the tight muscles fail, when stretching beyond one's active range of motion is necessary, and when the doctor wants to quantify the improvement of range of motion [5]. The treatment was done in a pain-free range of motion. Postural muscles are required to contract for long periods of time without rest, and are composed primarily of slow twitch fibers [6]. They respond best and strengthen fastest when exercises with slow and controlled movements occur [7].

    The ability to perform the range of motion in a pain-free zone is critical [7]. Early treatments were gentle and the exercises were of short duration while gaining the trust of the infant. Gentle traction of the humerus was applied while stabilizing the scapula to prevent jamming of the acromioclavicular joint and to minimize pain. Minimal range of motion only was applied. The neurological principals of cross-over, facilitation, and overflow were used. Both shoulders were exercised to maximize the cross-over effect [8]. Facilitation helps newly-formed soft tissue fibers develop healthy nerve axons by using motion to introduce controlled muscular contractions to set up the normal neurological pathways that encourage neuromuscular coordination. Each time the pathway is traversed, resistance is lowered and tonus results [9]. In overflow, a physiologic strength of 15 degrees on each side of the arc occurred, allowing benefits to occur without painful intrusion. No clicking was noted after the adjustment.

    Gentle massage was administered along the trapezoid and paraspinal musculature. In this case, the term "massage" is used to describe effleurage and gentle kneading of the soft tissue. The effects of massage include improved circulation and metabolic balance within the muscle, and inhibition of pain and reflexogenic guarding [101. Muscular contraction during normal activity mechanically helps eliminate toxic products into the lymphatic and venous flow.

DISCUSSION

    The metabolic balance of muscles is disturbed due to underactivity and overacitivity. Underactivity means not enough muscular contractions are occurring, whereas overactivity creates insufficient relaxation time for nutritive substances to flow in and by-products to flow out [10). Normal muscular activity does not happen when movement is too painful. Massage can help move the accumulation of waste products into the venous and lymphatic systems when normal muscle movement is limited or when there is hypertonicity. Furthermore, the infant's sustained muscle contraction due to the reflexogenic guarding was causing ischemia and more pain. Frequently the primary local arthrogenic pain is minimal and overridden by the secondary soft tissue pain. Deep massage may alter pain through stimulation of mechanoreceptors in the tendons and fascia during the stretching and compressing strokes and result in the inhibition of the sustained muscle contraction [6].

    The patient was provided the same treatment 5 days later, and again in 13 days. There were 32 adjustments over a course of approximately 5 months. They included a visit schedule of three times a week for two weeks, two times a week for seven weeks and one time a week for three months. The course of treatment, including evaluation, manipulation, massage, passive stretching, and rehabilitation exercises, was performed on 32 occasions and resulted in restoration of shoulder function. The course of six cervical manipulations over the three months resulted in decreased hypertonicity of the cervico-thoracic musculature. The infant was observed once a month for three months. The effectiveness of the treatment was determined by the fact that there would be crepitus and loss of shoulder function before the treatment in that the infant would stop using her arm. Treatment continued until the progress plateaued without incidence of irritation, aggravation, or exacerbation. Function returned after treatment. There was one reoccurrence of symptoms at 10 months of age, and there have been no reoccurrences as to date. Reoccurrences were noted by the parents; the infant would not use her left arm and hand to grasp, and crepitus would occur. The parents had been trained to note audible clicking upon movement of her left shoulder. The function of the shoulder would return to normal immediately after treatment. The infant continues to be monitored every month.

    This report shows that chiropractic manipulation and rehabilitation can be an important treatment option for acromioclavicular and cervical joint dysfunction in an infant. According to Pettibon, optimum structure precipitates optimum function [111. Shoulder and cervical joint dysfunction was corrected in this case by a relatively short course of treatment involving manipulation and rehabilitation. The effectiveness of the treatment was apparent in that normal function of the shoulder developed. The proprioceptive neuromuscular facilitation reestablished the neuromuscular pathways through the crossover effect with neuromuscular re-education. The massage therapy facilitated the reduction of the inflammation, enhanced the healing process, and gave the infant symptomatic relief. Passive rehabilitative exercises redeveloped and recreated passive normal movements of the involved musculature of the injured area. This in turn led to the return of normal tone and normal range of motion of the shoulder. The treatment was safe and effective.

CONCLUSION

    This report suggests that while the medical conclusion is that supportive care may be all that can be done for infants with shoulder and upper cervical dysfunction, chiropractic treatment for this infant produced beneficial results. A conservative treatment plan of shoulder manipulation, rehabilitative exercises and postural support may have a positive outcome for infants born with acromio-clavicular joint dysfunction and an upper cervical subluxation following a brow presentation malposition in utero. The acromio-clavicular joint was completely rehabilitated. The outcome for the infant could have been joint dysfunction, permanent hypertonicity of the cervical extensors, an atrophied limb, or loss of function. The constant pain could also have created a fearful child. This treatment protocol may also benefit other musculo-skeletal conditions which occur from birth trauma. Conservative chiropractic care can be an effective and important early intervention adjunct to pediatric care.

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